Skills vs. individual medicine

[Redneckreindeer]

Hi Everybody

I want to compromise the typical Paramedic skills with our German education for the E.M.S.

As normal in Germany we got only individual treatment. We got no skills. As the last two years in Germany they start to talk about it, the pro and contra for an skills based EMS.

I worked here in Germany at the red cross near Hamburg. We start to think about it too.

My question is, does anybody got some skills for scenes like "heart attack", "apoplexia" or "multiple Trauma".

I wanna say thanls for your posts.

Greets

Sunny

[Kiwiology]

Hi mate;

How do you mean you get no "skills" - surely you have some sort of interventions/scope of practice you can provide to patients?

I know the European system is heavily contrasted against the Anglo-American system in that it uses the Franco-German model in which physicians and nurses (either an intensivist, anaesthesologist/critical care or the like) are used to provide treatment with the other crewmember perhaps having some basic level skills and driving.

New Zealand is transitioning to a new system whereby we will have three levels of provider:

Ambulance Technician (Diploma)

- Oxygen

- OPA and NPA

- LMA

- Automated external defibrillator

- Combat application tourniquet (CAT)

- Aspirin PO and GTN SL for chest pain consistent with suspected myocardial ischemia (GTN also for acute CHF/APO)

- Acetaminophen PO for mild pain relief/fever

- Methoxyflurane for pain relief

- Glucagon IM

- Salbutamol neb

- Zofran PO

Paramedic (3 year Bachelor of Health Science in Paramedicine)

- IV cannulation (incl. EJ)

- IV fluid 0.9% NaCl

- 10% dextrose IV

- 3 and 12 lead ECG (3 lead interpret)

- Manual defibrillation

- Adrenaline IM/IV/neb

- Zofran IM/IV

- Naloxone IN/IM/IV

- Fentanyl IM/IN/IV

Intensive Care Paramedic (Post-Graduate Certificate + Bachelors Degree)

- Atropine IV

- Amiodarone IV

- Midazolam IV/IM/IN

- Ketamine IV/IM/IN

- IO cannulation

- 12 lead ECG interpret

- Cardioversion

- Pacing

- Endotracheal intubation

- Cricothyrotomy

- Suxamethonium IV (selected ICPs)

- Vecuronium IV (selected ICPs)

- Prehospital thrombolysis (currently being trialed)

There are one or two differences between services currently being ironed out - e.g. CPAP for CHF and corticosteriods for asthma and anaphylaxis. Some services also use magnesium and salbutamol IV for asthma as well as carrying ceftriaxone IV for meningococcal septicimea. I immagine most of these would be introduced nationally with the exception of ceftriaxone (except maybe in remote areas).

Now as far as "skills" for the situations you mentioned yes we do have them but it is very important to know we don't follow "cookbook" approaches to our patients; we have interventions to apply and use judgement/discretion in applying them although we do have standard approaches to assessing a patient. We will assess each patient along the same track generally and then go down one or more paths depending upon the symptoms; e.g. a "short of breath" would be asked some standard questions about history, onset, duration etc (SAMPLE/QRST as appropriate) and do a physical exam (e.g. lung sounds, signs of dyspnea/cyanosis) and if the symptoms fit say, shortness of breath consistent with astma, start a neb but everybody does not get the same treatment. Not everybody gets oxygen, or IV access/fluid, and just because you have crappy lung sounds does not mean you get frusemide. We also do not have to seek orders from a physician to provide treatment and have autonomy.

For somebody complaining of "chest pain" standard assessment is SAMPLE/QRRST, physical exam looking for dyspnea/SOB, diaphoresis, position (e.g. sitting up talking normally or do they appear in obvious pain; grey and sweaty doubled over in the recliner clutching thier chest?) etc. If it was a BLS crew (Technician) it would be appropriate to administer aspirin PO/sublingual GTN and consider transporting while calling for an ILS/ALS intercept if the patient was not improving.

ILS or ALS crews would look at thier ECG (either 3 or 12 lead) and again, deliver aspirin/GTN and fentanyl as appropriate for pain management. Prehospital thrombolysis for STEMI is being trialed here by our service (with good results) and has been introduced in one area already by another following thier successful trial. I am sunsure of what we use but WFA is using heprain/streptase.

Apoplexia (stroke/CVA) is not "treated" as such in the field because we do not have the assessment/treatment facilities required (ie our thrombolytics are for MI and not CVA because we cannot determine the type of stroke in the field).

The treatment of trauma focuses around appropriate stabilisation and quick transport because we are not surgeons. Cervical spine procedure here is vastly different from the US for example; we do not carry longboards and only use the scoop stretcher with a collar or KED as appropriate (I am not toally convinced anecdotally this is best but an 70/30 in favour of the scoop only as this seems to be where the evidence is pointing). We do reduce and splint [long] bone fractures as best as possible with cardboard splints as well as the Hare traction splint for leg fractures. Pain management is a very important part of trauma treatment and we are encouraged to make liberal use of combination analgesia (obviously we don't get the patient so sedated they are unable to breathe for themselves or anything silly like that but it's very important we provide adequate pain releif).

We are also given specific guidelines about fluid resuscitation in trauma patients with hypovolemic shock. Fluid is restricted to the minimum required to sutain life as we abide by the evidence of permissive hypotension. Shock from controlled bleeding gets fluid a little more liberally and if you want specific guidelines I can look them up.

As you can see we may be a little bit different, but not a whole lot perhaps I am not sure but we surely do not follow the American approach.

I do hope this helps and if you need any more information please do ask!

Edited September 30, 2009 by kiwimedic